Drug prescription patterns in schizophrenia outpatients: analysis of data from a German health insurance fund

INTRODUCTION

The aim of this study was to investigate routine administrative data from a major German health insurance fund, Techniker Krankenkasse, which covers 5.4 million insured individuals. Using a retrospective cohort design, this study analysed data collected from patients with a hospital diagnosis of schizophrenia in 2003 (index hospitalisation) in order to evaluate prescription patterns of antipsychotic drugs.

METHODS

Patients with an ICD-10 diagnosis of schizophrenia, at least one year prior membership with the insurance fund and a follow-up period of one year were identified. Results were standardised by age and stratified by the severity of their illness, defined by the number of hospital bed days during the three years preceding the index hospitalisation.

RESULTS

A total of 3,121 patients with schizophrenia (male 56.4%, female 43.6%) received 56 692 single prescriptions of antipsychotics. Of these, 35.4% of the prescriptions were for typical and 64.6% for atypical antipsychotics; 55% were for high-potency, 45% for low-potency typical antipsychotics. The most frequently prescribed drugs were olanzapine (26.6%), clozapine (21.3%) and risperidone (19%). There were no relevant gender differences concerning prescription patterns. During a 12-month follow-up period after the first hospitalisation, 1 372 patients (43.9%) were treated exclusively with an atypical antipsychotic, another 499 patients (16%) had a combination of an atypical plus a low-potency typical antipsychotic. Thus, basal therapy with an atypical was observed in 59.9% of our study population. Only 327 patients (10.5%) were treated exclusively with a typical antipsychotic. A total of 645 patients (20.7%) were treated with a combination of atypical plus typical antipsychotic. Changes of medication within one substance group occurred more often with typical antipsychotics (50%) as compared to atypical antipsychotics (25%).

DISCUSSION

At 60%, the proportion of patients in this study treated with atypical antipsychotics was surprisingly high. Of significant interest is the frequent prescription of clozapine (14%). The results are discussed in comparison to comparable studies from other countries.

Interferons and natalizumab for multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system which is accompanied by considerable disability and high costs. This report summarises the evidence on effectiveness and costs of beta-interferons and natalizumab in the treatment of multiple sclerosis.The review included systematic reviews and randomised controlled trials (with an observation time of at least one year) in patients with MS which assessed outcome parameters such as progression, exacerbations and adverse effects. An extensive literature search included databases such as MEDLINE, EMBASE, the Cochrane Library and various HTA-databases. Studies were selected according to predefined criteria, their quality was assessed according to criteria defined prospectively, and data were summarised systematically in tables. Cost-effectiveness evaluations were also included.Two systematic reviews and 24 randomised controlled trials of beta-interferon therapy were included, as well as three trials on the effectiveness of natalizumab. A total of 22 cost-effectiveness analyses for interferons were included, whereas no economic evaluations for natalizumab were identified.Use of interferon beta-1a or interferon beta-1b after a first demyelinating event led to a reduction of the conversion to definite MS during an observation time of two to three years. In relapsing remitting MS, interferon beta-1a reduced progression. The effects of interferon beta-1b on progression are unclear. Interferon beta-1a and interferon beta-1b reduced in some but not all studies outcomes relating to exacerbations. In direct comparison trials, interferon beta-1b (Betaferon(®) or Betaseron(®)) and interferon beta-1a (Rebif(®), higher dosage of 44 µg three subcutaneous injections per week) proved superior to interferon beta-1a (Avonex(®), 30 µg per week intramuscular) with respect to exacerbation outcomes. For secondary progressive MS, only one of five studies found a reduced progression with interferon beta-1a and only a part of the studies found an improvement with respect to outcomes relating to exacerbations. For primary progressive MS no advantage of therapy with beta-interferons was found with respect to patient-related outcomes. Beta-interferons showed characteristic and frequently occurring adverse effects, including reactions at the injection site and flu-like symptoms. A large proportion of patients stop interferon therapy because of adverse events. The other main reason for stopping therapy is the felt ineffectiveness of the treatment when patients experience a new exacerbation while on treatment. Many patients produce interferon-neutralising antibodies during therapy. The ultimate effect of neutralising antibodies on the efficacy of interferon treatment is unclear.In patients with relapsing remitting (and partially with secondary progressive) MS, treatment with natalizumab led to a reduction of progression and of exacerbation rates. However, a number of cases of progressive multifocal leucoencephalopathy have been reported after natalizumab therapy. These raise serious concerns about patient safety. Reliable data on the long term effectiveness of beta-interferons or natalizumab are not yet available.The absolute cost of interferon therapy is high and the available, international cost-effectiveness analyses indicate a high cost for achieving moderate benefits in quality of life. Further research is needed to provide specific cost-effectiveness estimates for Germany.

Effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care

BACKGROUND

In two recent randomised clinical trials, a meta-analysis and in an effectiveness study analysing routine data from the U.S. Veterans Administration the superiority of the newer atypical drugs over typical antipsychotic drugs, concerning both their efficacy and their side-effect profile, has been questioned.

AIMS OF THE STUDY

To analyse the effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care.

METHODS

Cohort study using routine care data from a statutory sickness fund with 5.4 million insured in Germany. To be included, patients had to be discharged with a diagnosis of schizophrenia in 2003 and fulfil membership criteria. Main outcome measures were rehospitalisation rates, mean hospital bed days, mean length of stay, cost of inpatient and pharmaceutical care to the sickness fund during follow-up and medication used to treat side-effects.

RESULTS

3121 patients were included into the study. There were no statistically significant differences in the effectiveness of atypical and typical antipsychotics on rehospitalisation during follow-up (rehospitalisation rate ratio 1.07, 95% confidence interval 0.86 to 1.33). However, there were consistent observations of atypical antipsychotics being more effective for severe cases of schizophrenia (14.6% of study population; >61 prior bed days per year in 2000-2002) in the follow-up period, whereas for the other severity strata typical antipsychotics seemed more effective in reducing various rehospitalisation outcomes. Patients treated with atypical antipsychotics received significantly less prescriptions for anticholinergics or tiaprid (relative risk 0.26, 95% confidence interval 0.18 to 0.38).

DISCUSSION

The effectiveness of atypical antipsychotics for schizophrenia on rehospitalisation measures appeared similar to that of typical antipsychotics. With the exception of severe cases, the higher costs for atypical antipsychotics were not offset by savings from reduced inpatient care. Major limitations include the lack of statistical power for subgroup analyses, the lack of clinical severity scale data and of life-course medical history data which both increase the risk of residual confounding by disease severity.

CONCLUSIONS

This study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

From a clinical perspective, this study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care.

IMPLICATIONS FOR HEALTH POLICIES

Routine data studies can yield valuable information for policy decision-makers on the costs and the effectiveness of pharmaceuticals in routine care, complementing efficacy data from randomised clinical trials currently used for licensing and reimbursement decisions.

IMPLICATIONS FOR FURTHER RESEARCH

The non-significant differences in the effectiveness of atypical compared to typical antipsychotics according to severity of disease should be investigated in a prospective observational study or in a randomised clinical trial.

Performance of reimbursement schemes in valuation of technologies: the example of magnetic resonance imaging

Different reimbursement schemes for health care providers have been developed worldwide. They have evolved over time and have been influenced by politics, costs, patient needs and technological progress. Different methods in the valuation of technologies and their reflection in outpatient reimbursement schemes are analyzed. Using Magnetic Resonance Imaging (MRI) as an example, five different reimbursement schemes from four countries are compared according to defined performance criteria. Major differences in the structure and valuation of internationally used reimbursement schemes are presented; Prices for Neurocranium MRI scans vary from euro98 to euro462 and large discrepancies can even be found within the same country. There are politically driven reimbursement schemes like the German Gebührenordnung für 'A'rzte, while others such as the Swiss TARMED are primarily based on actual costs.

Cross-country comparisons of costs: the use of episode-specific transitive purchasing power parities with standardised cost categories

International comparisons of healthcare costs are growing in importance for a number of different applications. The use of common approaches to converting costs such as GDP purchasing power parities (PPPs) often does not reflect price differences in healthcare in an appropriate manner. This means that new approaches need to be explored. The objective of this paper is to demonstrate the feasibility of using episode-specific PPPs (ESPPPs) to facilitate cross-country comparisons of healthcare costs and to compare this approach with other common approaches to conversion. Costs for five care episodes from hospitals in eight European countries were obtained from the EU HealthBASKET project. ESPPPs were created by using Fisher-type PPPs in combination with the Eltetö-Köves-Szulc method at the episode level. Differences in ESPPPs among the five care episodes were discussed and compared with other common conversion approaches. We found that ESPPPs-reflected prices and resource use more accurately than conventional conversion approaches such as GDP PPPs and medical care PPPs. This was particularly evident for labour-intensive care episodes in which other conversion approaches revealed problems in the way that labour input had not been considered appropriately. The results demonstrate that ESPPPs are preferable to other common conversion approaches when international healthcare cost comparisons are performed.

Analysis of differences in proportions from clustered data with multiple measurements in diagnostic studies

OBJECTIVES

In diagnostic studies, proportions such as sensitivities are often to be calculated and to be compared between different diagnostic procedures. As statistical unit of analysis, multiple observational units may be assessed within each patient, i.e., multiple lesions in an organ. As a requirement, these are to be assessed by multiple blinded readers. In this paper we propose a method to cover correlations between units within patients, correlations between procedures and correlations between different raters assessing each observational unit.

METHODS

The proposed approach is a two-step method to analyze clustered data with multiple measurements to compare diagnostic procedures in a paired modality design and the correlation between the readers in a paired reader design. The performance of the approach was compared to a generalized estimation equations model (GEEs) by power simulations.

RESULTS

Power simulations suggest, that the two-step approach is not inferior to GEEs with regard to the single readers as well as with regard to the average reader.

CONCLUSIONS

An intuitive approach was developed next to established methods to analyze "paired modality, paired reader" and "unpaired modality, paired reader" studies with binary endpoints when estimating proportions and differences in proportions for clustered data with multiple measurements. This two-step approach is an alternative method to cover routine designs of diagnostic studies where the difference of proportions is to be estimated directly along with confidence intervals.

Pricing behaviour of pharmacies after market deregulation for OTC drugs: The case of Germany

OBJECTIVE

To examine the price reactions of German pharmacies to changes made to OTC drug regulations in 2004. Prior to these changes, regulations guaranteed identical prices in all German pharmacies.

METHODS

Two years after market deregulation, 256 pharmacies were surveyed to determine the retail prices of five selected OTC drugs. A probit regression model was used to identify factors that increased the likelihood of price changes. In addition, 409 pharmacy consumers were interviewed to gather information on their knowledge of the regulatory changes and to better explain consumer behaviour.

RESULTS

Data was collected on a total of 1215 prices. Two years after deregulation, 23.1% of the participating pharmacies had modified the price of at least one of the five OTCs included in our study. However, in total, only 7.5% of the prices differed from their pre-deregulation level. The probit model showed that population density and the geographic concentration of pharmacies were significantly associated with price changes. Interestingly, the association with the geographic concentration of pharmacies was negative. The consumer survey revealed that 47.1% of those interviewed were aware of the deregulation.

CONCLUSIONS

Our findings indicate that, two years after deregulation, very few pharmacies had made use of individual pricing strategies; price competition between pharmacies in Germany is thus taking place only a very small scale.

Ventricular assist devices for heart failure

BACKGROUND

Heart failure is a clinical syndrome of major epidemiological and economical importance. In Germany as in other industrialised countries it is one of the leading causes of mortality, morbidity and disability. For patients not responding to medical therapies ventricular assist devices are used as bridge to transplant, bridge to recovery or as destination therapy alternative to transplantation.

RESEARCH QUESTIONS

This report aims to present the actual evidence on clinical effectiveness, psychological and social aspects and economical aspects of left ventricular assist devices.

METHODS

We conducted a systematic research of the literature in different databases (EMBASE, MEDLINE, Cochrane Library). The included studies were assessed by two reviewers and were presented in tables and in a narrative form. We also conducted a survey among hospitals using the technology.

RESULTS AND DISCUSSION

We included 40 references, six of them were HTA-reports. LVAD patients as bridge to transplant had better survival rates and a better quality of life as compared to medical therapy. Mechanical assistance was associated with frequent and often serious adverse events which were often the cause of death. There were numerous psychological and psychiatric problems.

CONCLUSIONS/RECOMMENDATIONS

LVAD showed to be clinically effective, however with high complications rate and seriousness of them. The use of technology is very costly. Cost-effective should be analysed for Germany. There is a need to further develop the technology before it can contribute seriously to a reduction of the need for heart transplantation.

Zur Strategieanfälligkeit der Arzneimittelkomponente des IPHCC+RxGroups-Klassifikationssystems in einem morbiditätsorientierten Risikostrukturausgleich - Eine konzeptionelle und datengestützte Analyse

BACKGROUND

A report commissioned by the German Ministry of Health recommends to the existing scheme for calculating risk-adjusted transfers to sickness funds supplement with the IPHCC+RxGroups method. The method is based on inpatient diagnoses and prescribed drugs as health status measures deduced from prior use.

OBJECTIVE

The present study investigates the sickness fund's expected net return from gaming based on the drug component of the risk adjuster.

METHODS

The study explores three possible strategies using the RxGroups method. For the stimulations, insurees are assigned to additional indications or to higher valued RxGroups within the same indication. Then, costs and financial benefits attributable to the altered drug use are estimated and compared with the status quo. The study uses 2000 and 2001 sample data of more than 370,000 insurees of Germany's company-based sickness funds system (BKK).

RESULTS

While upgrading increases overall costs, it can be beneficial for the individual sickness funds. Their net return crucially depends on the number of sickness funds gaming the system: the more participating in the game, the smaller is the average net return. Moreover, not participating often is even worse, which in turn points to a prisoner's dilemma.

CONCLUSIONS

When extending the risk adjustment scheme in social health insurance, the German legislator should take into account the perverse incentives of risk adjusters such as the described prescription drug model.

Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system?

Germany has recently introduced a system of Diagnosis Related Groups (DRGs) to engender more appropriate resource allocation. The following article describes the German DRG-system and the methodologies used to determine prices. It analyses the extent to which prices, or calculated cost weights, reflect the actual costs incurred by hospitals for their respective services. We reveal that a "compression" of DRG cost weights occurs, and that the data sample used to calculate cost weights is lacking in terms of its representativeness. Although cost data accuracy has improved over the last few years there are still a number of challenges that need to be addressed.

Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries

Over the past 20 years, most European countries have introduced DRGs or similar grouping systems as instruments for hospital reimbursement. This paper compares and analyzes the methods used to determine prices for inpatient care within DRGs or similar grouping systems employed in nine EU member states (i.e., Denmark, France, Germany, Hungary, Italy, Tthe Netherlands, Poland, Spain and England). It categorizes the systems of patient classification used in these nine countries and compares them according to the three steps necessary in order to set prices: 1.) definition of a data sample, 2.) use of trimming methods and plausibility checks and 3.) definition of prices. It concludes with a discussion on the typical development path of DRG systems and the role of additional reimbursement components in this context.

Mistletoe treatments for minimising side effects of anticancer chemotherapy

BACKGROUND

More than 200,000 persons died in 2002 in Germany as a consequence of cancer diseases. Cancer (ICD-9: 140-208, ICD-10: C00-C97) accounted for 28% of all male deaths and for 22% of all female deaths. Cancer treatment consists on surgery, radio- and chemotherapy. During chemotherapy patients may experience a wide variety of toxic effects (including life-threatening toxicity) which require treatment. The type and the intensity of chemotherapy toxicity are one of the limiting factors in cancer treatment. Toxic effects are also one of the factors affecting health related quality of life (HRQOL) during chemotherapy. Mistletoe extracts belong to the group of so called "unconventional methods" and are used in Germany as complementary cancer treatments. It has been postulated that the addition of mistletoe to chemotherapeutical regimes could help reduce chemotherapy-induced toxicity and enhance treatment tolerability. The German social health insurance covers the prescription of ML I standardized mistletoe extracts when those are prescribed as palliative cancer treatments with the aim of improving HRQOL.

RESEARCH QUESTIONS

Does the addition of mistletoe to chemotherapeutical regimes reduce their toxicity?Does the addition of mistletoe to chemotherapeutical regimes contribute to improve quality of life?Has the addition of mistletoe to chemotherapeutical regimes any effects on survival?Has the addition of mistletoe to chemotherapeutical regimes any effects on tumor-remission?

METHODS

WE CONDUCTED A SYSTEMATIC LITERATURE SEARCH IN FOLLOWING DATABASES: The Cochrane Library, DIMDI Superbase and Dissertation Abstracts. We included systematic reviews and randomized controlled trials (RCT). Appraisal of literature was done by two authors independently. Checklists were used to guide literature appraisal. The Jadad-Score was used to score quality of RCT. Evidence was summarized in tables and in narrative form.

RESULTS AND DISCUSSION

The literature search yielded 437 potentially relevant papers. A total of 94 papers was retrieved. Of them, 48 were potentially relevant for answering the research questions and 46 for background information. In this report we summarize the results from three systematic reviews, five published RCT and two unpublished RCT. A protocol of an ongoing systematic review from the Cochrane Collaboration was also identified. The information gathered from the systematic reviews was insufficient to answer the research questions. The relevant studies identified and synthetised in these reviews were appraised and extracted again. In addition, a set of recently published RCT was identified and included in these report. None of the RCT defined frequency or severity of chemotherapy associated toxic effects as its primary outcome. Some of the RCT reported, however, rates of toxic effects or parameters related to toxicity. The results are inconsistent among the RCT ranging from no effect on to positive effects (i. e. reduction) on chemotherapy toxicity. RCT with treatment toxicity as primary outcome are needed to answer the question of whether the addition of mistletoe extracts to chemotherapy regimes can help reducing treatment toxicity. HRQOL was the primary outcome in four RCT. The addition of mistletoe to chemotherapy showed to have a positive effect on HRQOL of women treated for breast cancer.

CONCLUSIONS

The available evidence does not allow giving a conclusive answer to the question of whether the addition of mistletoe to chemotherapeutical regimes can reduce the toxicity of the latter. RCT are needed in which the primary outcome is treatment toxicity. The addition of standardised mistletoe extract to chemotherapeutical regimes in the treatment of women with breast cancer can lead to improvements in HRQOL. In the light of the results from RCT the coverage of mistletoe in cancer treatment should be restricted in Germany to the latter indication.

Editorial: Hospital case payment systems in Europe

Since the introduction of the system of diagnosis related groups (DRGs) for USA Medicare patients in 1983, case payment mechanisms have gradually become the principal means of reimbursing hospitals in most developed countries. The use of case payments nevertheless poses severe technical and policy challenges, and there remain many unresolved issues in their implementation. This paper introduces a special issue of the journal that describes and compares experience with the use of case payments for reimbursing hospitals in nine European countries. The editorial sets the policy scene, and argues that DRG systems must be seen both as a technical reimbursement method and as a fundamental incentive mechanism within the health system.